新发阿尔茨海默病或相关综合征患者生命最后一年中不良医疗服务利用轨迹的潜在决定因素：一项使用行政数据的全国性队列研究
Potential determinants of unfavourable healthcare utilisation trajectories during the last year of life of people with incident Alzheimer Disease or Related Syndromes: a nationwide cohort study using administrative data.
作者信息
Elyn Antoine, Gardette Virginie, Renoux Axel, Sourdet Sandrine, Nourhashemi Fati, Sanou Brigitte, Dutech Michel, Muller Philippe, Gallini Adeline
机构信息
CERPOP, UMR1295, Unité Mixte INSERM - Université Toulouse III Paul Sabatier, Axe Maintain, Aging Research Team, University Toulouse III Paul Sabatier, 37 Allées Jules Guesde, 31000 Toulouse, France.
Pain Evaluation and Treatment Center, Neurosciences Department, University Hospital of Toulouse, Place du Dr Joseph Baylac, TSA 40031, 31059 Toulouse Cedex 9, France.
出版信息
Age Ageing. 2022 Mar 1;51(3). doi: 10.1093/ageing/afac053.
BACKGROUND
people approaching the end-of-life frequently face inappropriate care. With Alzheimer Disease or Related Syndromes (ADRS), end-of-life is characterised by progressive decline, but this period remains difficult to identify. This leads to a lack of anticipation and sometimes with unfavourable healthcare utilisation trajectories (HUTs).
OBJECTIVE
to quantify unfavourable HUTs during the last year of life and identify their potential determinants in both community and nursing-home settings.
DESIGN
nationwide cohort study using administrative database.
SETTING
French community and nursing-home residents.
SUBJECTS
incident ADRS people identified in 2012, who died up to 31 December 2017.
METHODS
we used multidimensional clustering to identify 15 clusters of HUTs, using 11 longitudinal healthcare dimensions during the last year of life. Clusters were qualitatively assessed by pluri-disciplinary experts as favourable or unfavourable HUTs. Individual and contextual potential determinants of unfavourable HUTs were studied by setting using logistic random-effect regression models.
RESULTS
62,243 individuals died before 31 December 2017; 46.8% faced unfavourable end-of-life HUTs: 55.2% in the community and 31.8% in nursing-homes. Individual potential determinants were identified: younger age, male gender, ADRS identification through hospitalisation, shorter survival, life-limiting comorbidities, psychiatric disorders, acute hospitalisations and polypharmacy. In the community, deprivation and autonomy were identified as potential determinants. Contextual potential determinants raised mostly in the community, such as low nurse or physiotherapist accessibilities.
CONCLUSIONS
Nearly half of people with ADRS faced unfavourable HUTs during their last year of life. Individual potential determinants should help anticipate advance care planning and palliative care needs assessment. Contextual potential determinants suggest geographical disparities and health inequalities.
背景
临终患者常常面临不适当的护理。对于阿尔茨海默病或相关综合征（ADRS）患者，临终阶段的特点是病情逐渐恶化，但这一时期仍难以确定。这导致缺乏预期，有时还会出现不利的医疗利用轨迹（HUTs）。
目的
量化生命最后一年中不利的HUTs，并确定其在社区和养老院环境中的潜在决定因素。
设计
使用行政数据库进行全国性队列研究。
地点
法国社区和养老院居民。
研究对象
2012年确诊的ADRS患者，于2017年12月31日前死亡。
方法
我们使用多维聚类方法，根据生命最后一年的11个纵向医疗维度，识别出15种HUTs聚类。多学科专家对这些聚类进行定性评估，分为有利或不利的HUTs。通过使用逻辑随机效应回归模型，按环境研究不利HUTs的个体和背景潜在决定因素。
结果
62243人于2017年12月31日前死亡；46.8%的人面临不利的临终HUTs：社区为55.2%，养老院为31.8%。确定了个体潜在决定因素：年龄较小、男性、因住院确诊ADRS、生存期较短、有限制生命的合并症、精神障碍、急性住院和多重用药。在社区中，贫困和自主性被确定为潜在决定因素。背景潜在决定因素大多出现在社区，如护士或物理治疗师可及性较低。
结论
近一半的ADRS患者在生命的最后一年面临不利的HUTs。个体潜在决定因素应有助于预测预先护理计划和姑息治疗需求评估。背景潜在决定因素表明存在地域差异和健康不平等。
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